Nash_Well Abandonment_20231122 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Lawrence D. O er 9
PP 7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple 'injection or non-water 'supply wells ONLY with the same
construciionlahandonment,you can submit one form.
3322-A
NC Well Contractor Certification Number
7b.Approximate volume of water remaining in well(s): (gal.)
Regional probing Services FOR WATER SUPPLY WELLS ONLY:
Company Name 7e.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
OMonitoring ❑Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:'
❑Aquifer Recharge ❑Groundwater Remediation bentonite chips:1.6 Ibs/ft(37-44 Ibs/well) Nil I 9 �`
❑Aquifer Storage and Recovery ❑Salinity Barrier �2023
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g•Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Filled/hydrated from bottom-up. Capped with concrete.
❑Geothermal(Heating/Cooling Return) El Other(explain under 7g)
MW-1(24.5'),M W-2(25.5'),MW-3(26'),MW-4(27.5'),MW-5(23.5')
4.Date well(s)abandoned: 9/27/2023 MW-6(1.5'),MW-7(23.5'),MW-8(26'),MW-9(26')
5a.Well location: MW-6 was previously abandoned to 1.5'bls.
Fiendly Food Mart NCDEQ Incident#9037
Facility/Owner Name Facility ID#(ifapplicable) $•Certification:
1002 North Church Street, Rock Mount Lawrence O °° °°�- -
Y P �s 9/28/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Nash By signing this form, I hereby certify that the well(s)was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.955347 77.792034 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: Monitoring Wells-see 7g abandonment to the following:
Division of Water Quality,Information Processing Unit,
66.Total well depth: (ft.)
23.5-27.5 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
well I.D.=2.0 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
approx 19 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) the address(es) above, also submit'one copy of this form.within 30 days of
completion of well abandonment to,''the county health department of the county
where abandoned.
6E Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013
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